NHS Highland didn't carry out key tests on pregnant mum who gave birth to stillborn twin, SPSO rule

A mother gave birth to a stillborn twin after a health board failed to carry out key tests during her pregnancy.

A patient complained that NHS Highland failed to provide reasonable care and treatment during her pregnancy, leading to the loss of one of her babies.

The Scottish Public Services Ombudsman, who investigated the complaint, found that key measurements and tests were not carried out, going against guidelines.

As a result, this impacted on clinicians ability to properly assess what kind of care the patient needed.

The mother also raised a complaint that the NHS board failed to investigate her concerns.

The watchdog found that while many aspects of the reviews which were carried out were reasonable, they did not identify the significance that the lack of the measurements being taken was unreasonable, leading to a delay in identifying information that could be taken forward.

NHS Highland has issued an apology to the patient.

A spokesperson for the health board said: “NHS Highland apologises for our failings in the care and treatment provided to this patient.

“We accept the findings in the SPSO report and have written to the family to apologise and advise that we are taking steps to identify and act on the learning from this case.”

Among its recommendations, the Scottish Public Services Ombudsman (SPSO) said that going forward reviews should be thorough and identify all relevant learning from an event.

The watchdog added that where there are growth issues with a fetus, “appropriate investigations and tests, including measuring the pulsatility index as required, should be carried out in line with relevant national guidance”.

The SPSO received independent advice from a consultant obstetrician and gynaecologist for the report.